Uniform Mitigation Verification Inspection Form Maintain a copy of this form with insurance policy Inspection Date: 08/12/2011 Owner Information Owner Name: Steve Owner Contact Person: Joe Contact Address: 123 Somewhere Street Home Phone: 123-456-7890 City: Palm Coast FL Zip: 32137 Work Phone: 123-456-7899 County: Flagler Cell Phone: 123-456-7889 Insurance Company: State Farm Policy #: Unknown Year of Home: 2007 # of Stories: 1 Email: sowner@gmailcom I, Adam Singer (print name of the individual who actually performed the inspection), personally conducted the inspection of the residence identified on this form and in my professional opinion, all the data I reported is true and correct 1 Building Code: What building code was used to design and build the structure? A 1994 South Florida Building Code (building permit application date of 9/1/1994 or later in Miami-Dade and Broward Counties (also known as the High Velocity Hurricane Zone (HVHZ)) B Building code prior to the 1994 South Florida Building Code (building permit application date of 8/31/1994 or earlier in Miami-Dade and Broward Counties (HVHZ) C 2001 Florida Building Code (building permit application date of 3/1/2002 or later outside the HVHZ) D Building code prior to the 2001 Florida Building Code (building permit application date of 2/28/2002 or earlier outside the HVHZ) E Unknown or undetermined 2 Predominant Roof Covering: Permit Application Date: or Date of Installation: 2007 A At a minimum meets the 2001 Florida Building Code or the 1994 South Florida Building Code and has a Miami-Dade NOA or FBC 2001 Product Approval listing demonstrating compliance with ASTM D 3161 (enhanced for 110MPH) OR ASTM D 7158 (F, G or H), OR FBC TAS 100-95 and TAS 107-95, OR FMRC 4470 and/or 4471 (for metal roofs) Does not meet the above minimum requirements Unknown or Undetermined NOTE: At least one photo documenting the existence of each visible and accessible construction or mitigation attribute marked in Sections 3 through 9 must accompany this form 3 Roof Deck Attachment: What is the weakest form of roof deck attachment? A Plywood/Oriented strand board (OSB) roof sheathing attached to the roof truss/rafter (spaced a maximum of 24" oc) by staples or 6d nails spaced at 6" along the edge and 12" in the field -OR- Batten decking supporting wood shakes or wood shingles-or- Any system of screws, nails, adhesives, other deck fastening system or truss/rafter spacing that has an equivalent mean uplift resistance of 55 psf B Plywood/OSB roof sheathing with a minimum thickness of 7/16" attached to the roof truss/rafter (spaced a maximum of 24" oc) by 8d common nails spaced 6" along the edge and 12" in the field-or- Any system of screws, nails, adhesives, other deck fastening system or truss/rafter spacing that has an equivalent mean uplift resistance of 103 psf C Plywood/OSB roof sheathing with a minimum thickness of 7/16" attached to the roof truss/rafter (spaced a maximum of 24" oc) by 8d common nails spaced 6" along the edge and 6" in the field -OR- Dimensional lumber/tongue & Groove decking with a minimum of 2 nails per board -OR- Any system of screws, nails, adhesives, other deck fastening system or truss/rafter spacing that has an equivalent mean uplift resistance of 182 psf D Reinforced Concrete Roof Deck *This verification form is valid up to five (5) years provided no material changes have been made to the structure OIR-B1-1802 (Rev 02/10) Adopted by Rule 69O-1700155
E Other: F Unknown or unidentified G No attic access 4 Roof to Wall Attachment: What is the weakest roof to wall connection? A Toe Nail Rafter/truss anchored to top plate of wall using nails driven at an angle through the rafter/truss and attached to the top plate of the wall B Clips Metal attachments on every rafter/truss that are nailed to one side (or both sides in the case of a diamond type clip) of the rafter/truss and attached to the top plate of the wall frame or embedded in the bond beam C Single Wraps Metal Straps must be secured to every rafter/truss with a minimum of 3 nails, wrapping over and securing to the opposite side of the rafter/truss with a minimum of 1 nail The Strap must be attached to the top plate of the wall frame or embedded in the bond beam in at least one place D Double Wraps Both Metal Straps must be secured to every rafter/truss with a minimum of 3 nails, wrapping over and securing to the opposite side of the rafter/truss with a minimum of 1 nail Each Strap must be attached to the top plate of the wall frame or embedded in the bond beam in at least one place E Structural Anchor bolts, structurally connected or reinforced concrete roof F Other: G Unknown or Unidentified H No attic access 5 Roof Geometry: What is the roof shape(s)? (Porches or carports that are attached only to the fascia or wall of the host structure and not structurally connected to the main roof system are not considered in the roof geometry determination) A Hip Roof Hip roof with no other roof shapes greater than 10% of the total building perimeter B Non-Hip Roof Any other roof shape or combination of roof shapes including hip, gable, gambrel, mansard and other roof shapes not including flat roofs C Flat Roof Flat roof shape greater than 100 square feet or 10% of the entire roof, whichever is greater 6 Gable End Bracing: For roof structures that contain gables, please check the weakest that apply: A Gable End(s) are braced at a minimum in accordance with the 2001 Florida Building Code B Does not meet the above minimum requirements C Not applicable, unknown or unidentified 7 Wall Construction Type: Check all wall construction types for exterior walls of the structure and percentages for each: A Wood Frame % B Un-Reinforced Masonry % 30 C Reinforced Masonry % 70 D Poured Concrete % E Other % 8 Secondary Water Resistance (SWR): (standard underlayments or hot mopped felts are not SWR) A SWR Self adhering polymer modified bitumen roofing underlayment applied directly to the sheathing or foam adhesive SWR barrier (not foamed on insulation) applied as a secondary means to protect the dwelling from water intrusion B No SWR C Unknown or undetermined 9 Opening Protection: What is the weakest form of wind borne debris protection installed on the structure? (Exterior openings include, but are not limited to: windows, doors, garage doors, skylights, etc Product approval may be required for opening protection devices without proper rating identification) A All Exterior Openings (Glazed and Unglazed) All exterior openings are fully protected at a minimum with impact resistant coverings, impact resistant doors and/or impact resistant window units that are listed as wind borne debris protection devices in the product approval system of the State of Florida or Miami-Dade County and meet the requirements of one of *This verification form is valid up to five (5) years provided no material changes have been made to the structure OIR-B1-1802 (Rev 02/10) Adopted by Rule 69O-1700155
the following for "Cyclic Pressure and Large Missile Impact" For the HVHZ, systems must have either a Miami-Dade NOA or FBC Approval marked "For Use in the HVHZ" Miami-Dade County Notice of Acceptance (NOA) 201, 202 and 203 (Large Missile - 9 lb) Florida Building Code Testing Application Standard (TAS) 201, 202 and 203 (Large Missile - 9 lb) American Society for Testing and Materials (ASTM) E 1886 and ASTM E 1996 (Large Missile - 9 lb) Southern Standards Technical Document (SSTD) 12 (Large Missile - 9 lb) For Skylights Only: ASTM E 1886/E 1996 (Large Missile - 45 lb) For Garage Doors Only: ANSI/DASMA 115 (Large Missile - 9 lb) B All exterior openings are fully protected at a minimum with impact resistant coverings, impact resistant doors and/or impact resistant window units that are listed as windborne debris protection devices in the product approval system of the State of Florida or Miami-Dade County and meet the requirements of one of the following for "Cyclic Pressure and Large Missile Impact": ASTM E 1886 and ASTM E 1996 (Large Missile - 45 lb) SSTD 12 (Large Missile - 4 lb to 8 lb) For Skylights Only: ASTM E 1886/E 1996 (Large Missile - 2 to 45 lb) C All exterior openings are fully protected at a minimum with impact resistant coverings, impact resistant doors and/or impact resistant window units that are listed as windborne debris protection devices in the product approval system of the State of Florida or Miami-Dade County and meet the requirements of one of the following for "Cyclic Pressure and Small Missile Impact": Miami-Dade County NOA 201, 202 and 203 (Small Missile - 2 grams) Florida Building Code TAS 201, 202 and 203 (Small Missile - 2 grams) ASTM E 1886 and ASTM E 1996 (Small Missile - 2 grams) SSTD 12 (Small Missile - 2 grams) D All exterior openings are fully protected with windborne debris protection devices that cannot be indentified as Miami-Dade or Florida Building Code (FBC) product approved This does not include plywood/osb or plywood alternatives (see Answer "H") All Glazed Exterior Openings E All glazed exterior openings are fully protected at a minimum with impact resistant coverings and/or impact resistant window units that meet the requirements of one of the standards listed in Answer "A" of this question (Large Missile - 9 lb) F All glazed exterior openings are fully protected at a minimum with impact resistant coverings and/or impact resistant window units that meet the requirements of one of the standards listed in Answer "B" of this question (Large Missile - 2 lb- 8 lb) G All glazed exterior openings are fully protected at a minimum with impact resistant coverings and/or impact resistant window units that meet the requirements of one of the standards listed in Answer "C'"of this question (Small Missile - 2 grams) H All glazed exterior openings are covered with plywood/osb meeting the requirements of Section 1609 and Table 160914 of the 2004 FBC (with 2006 supplements) I All glazed exterior openings are fully protected with wind-borne debris protection devices that cannot be identified as Miami-Dade or FBC product approved This does not include plywood/osb or other plywood alternatives that do not meet Answer H (see Answer "K") None or Some Glazed Openings J At least one glazed exterior opening does not have wind-borne debris protection K No glazed exterior openings have wind-borne debris protection This includes plywood/osb or plywood alternative systems that do not meet Answer "H" L Unknown or undetermined *This verification form is valid up to five (5) years provided no material changes have been made to the structure OIR-B1-1802 (Rev 02/10) Adopted by Rule 69O-1700155
MITIGATION INSPECTIONS MUST BE PERFORMED BY A QUALIFIED INSPECTOR Section 627711(2), Florida Statutes, provides a listing of individuals who may sign this form Qualified Inspector Name: Adam Singer License Type: GC Lic # 123 License # or MSFH certificate #: CES-10-MI-00123 Inspector Name Adam Singer Company Name PDmB, Inc Company Phone: 513-522-7362 Qualified Inspector - I hold an active license or certificate as a: (check one) Hurricane mitigation inspector certified by the My Safe Florida Home Program Building code inspector certified under Section 468607, Florida Statutes General, building or residential contractor licensed under Section 489111, Florida Statutes Professional architect licensed under Section 481213, Florida Statutes Professional engineer licensed under Section 471015, Florida Statutes Other individual or entity recognized by the insurer as possessing the necessary qualifications to properly complete this form pursuant to Section 627711(2)(f), Florida Statutes Individuals signing this form must have their license or certificate in an "Active" status at time of the inspection I, Adam Singer am a qualified inspector and I personally performed the inspection or had my employee ( ) perform the inspection and I agree to be responsible for his/her work Qualified Inspector Signature: Date: 8/12/11 An individual or entity who knowingly provides or utters a false or fraudulent mitigation verification form with the intent to obtain or receive a discount on an insurance premium to which the individual or entity is not entitled commits a misdemeanor of the first degree (Section 627711(3), Florida Statutes) The Qualified Inspector who certifies this form is strictly liable for all acts, statements, concealment of facts, omissions, and documentation provided by his or her employee who actually performed the inspection Homeowner to complete: I certify that the named Qualified Inspector or his or her employee did perform an inspection of the residence identified on this form and that proof of identification was provided to me or my Authorized Representative Signature: Date: 8/12/11 An individual or entity who knowingly provides or utters a false or fraudulent mitigation verification form with the intent to obtain or receive a discount on an insurance premium to which the individual or entity is not entitled commits a misdemeanor of the first degree (Section 627711(3), Florida Statutes) The definitions on this form are for inspection purposes only and cannot be used to certify any product or construction feature as offering protection from hurricanes *This verification form is valid up to five (5) years provided no material changes have been made to the structure OIR-B1-1802 (Rev 02/10) Adopted by Rule 69O-1700155
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